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Larry Fallat
has nothing to disclose.

Lecture Transcript

Male Speaker: This is a topic that’s going to cover many subjects. Let me just see how much time I’ve got here. 8:35, so I have about 40 minutes. I’m going to run through this. We’ll cover as much of this as we can. The goals of this presentation, I want you to become familiar with some of the less common forms of trauma, be familiar with management and outcomes of some of this trauma and we’re going to look at alternative fixation of fractures. I’m going to have a section in here on fixation of fractures and osteoporotic or neuropathic bone and just become familiar with the basics of management of soft tissue trauma and gunshot wounds. I’m going to start off with this case report. This is very nice gentleman. What’s important here is his diabetes, his pronounced neuropathy, his osteoporosis and he had an IM rod for a tibial fracture in 2001. When he came in to the office, he sees my partner, Dr. Morrison and he had a paper printout of his fibular fracture. Let’s see. Right here you can see it and here’s his old fracture up here. He had a Lisfranc fracture dislocation. We thought, “Okay, he’s got all these risk factors but we needed to operate because we know how any kind of fracture in a patient with diabetic neuropathy can just turn to garbage very quickly.” We thought we are pretty cool. We did this percutaneous plate fixation. No periosteal dissection. We didn’t devitalize the bone or anything. This looks good and he used the syndesmotic screw. That’s what his x-rays look like of the ankle and we did the percutaneous fixation first. That’s what the foot looks like. We used an intramedullary beam to stabilize the medial column because we’re worried and paranoid about this foot just turning bad on this. Anyway, we patted ourselves on the back and three weeks later the patient came in. If you take a look, he didn’t hear anything. He didn’t feel anything. Nothing popped, shifted, moved. If you look at his x-ray, look at the lateral view. You can see his foot is dislocated posteriorly. If you look at the screws, these ones are pulled out as a plate. That’s the nature of this bone in people with neuropathy and osteoporosis. His Lisfranc fracture has pulled apart. We didn’t have a nonweightbearing. I mean that’s the biggest fallacy that we have. People can’t stay nonweightbearing. They can’t, especially if you’re heavy and you’re compromised in any way. You don’t have the strength to use crutches and some people even struggle with a walker. Anyway, here we have him. He’s three weeks out. He shows up to the office. His foot’s all jacked up. What would you do? Here are the choices. Revision of the surgery. Just open at this time and repair everything, an external fixator, immobilization fuse, the ankle joint are just jump right to an amputation. Now, remember, we’re all surgeons and so we think like surgeons. We want to operate and that’s what I did. Here’s the line of thinking. I gave up my best shot and, yes, I looked at the x-ray, I know I can make it better, whether we use an IM now or whatever we use, an external fixator, this guy is at high risk. I thought, I’m not burying my head in the sand but let’s go with this and just how he does, I can step in at any point intervene and fix it. Six weeks out, take a look at that lateral. Now, I’m thinking, what the heck that I just do and my partner is looking at me like, “What did I get into?” She’s saying. Well, 10 weeks, now we’re starting to see some bone callus formation. Six months, it’s stable. He’s not displacing anymore. The foot is consolidating and healing. Here he is at six months. He can bear weight on it. Twelve months, it continues to remodel. Looks good. He’s getting something syndesmosis between the tibia and fibula which is a bonus. The foot looks good. Here he is two years postop. He’s completely consolidated. He’s functioning. He’s got a stable plantigrade foot. Is it pretty no, but I did not subject him to any other risk factors. He’s able to function. He’s wearing his CROW and he’s mobile. He’s moving around. He’s able to take care of himself. The whole point of this case is this is what can happen with that neuropathic osteoporotic bone in our diabetic neuropathy patients. Here’s another one. This is a real life case.

[05:03]

A very pleasant lady, 65-year-old female but take a look at her BMI. It’s 72.4. Her weight is just about 400 pounds [coughs], excuse me. Let me show you what she has and she’s got this ankle fracture, very unstable. We know it’s unstable because she’s telling even with the makeshift splint we put on her. It’s moving. She feels it grinding. Let me show you this. This is what we knew. I mean it very easily displaces and got to do something. Anyway, this is what her limb looks like. This presents a whole series of problems. The question to you as residents, what would you do? Remember, whatever you do, you’ve got to live with this lady. Immobilize her, okay, you can. It’s very hard to put a cast or brace or splint on somebody with that type of girth to the lower extremity. Operate, open it up. Fixate this thing. The bone is like mash. Conventional fixation or external fixator or primary arthrodesis. I showed you her comorbidities. If you’re going to do anything in the world of surgery, it’s got to be very quick too. Here’s what I did. Closed reduction, percutaneous transarticular fixation. If you’re not familiar with this [coughs], excuse me, it’s simply involves reducing the fracture and shooting the Steinmann rods up through the bottom of the heel. This is very fast and furry. Very fast and it’s very strong too. It stabilizes the ankle joint. It stabilizes the rearfoot at the same time. You see this all we did. We do not make an incision. If we made an incision through those folds of adipose tissue, the incisions become macerated. They dehisced. They become infected. I’ve been through this with other patients in the past. If you operate and you make the incisions, there so much adipose tissue that is extremely difficult to retract so you can see the fracture site. It’s difficult to position the leg even if you go to a lateral decub but still it’s difficult. If you use conventional fixation, that bone is like mash. It’s like putting a screw in Balsa wood and that can pull right out. Whatever we do, we need to stabilize this very unstable bimalleolar ankle fracture. This is where transarticular fixation comes is. Jenny [phonetic] was one of the first to describe this for diabetic neuropathy. This is a technique. I only have done this maybe six times over the years and has always been in cases similar to this. You’re just very limited to what you can accomplish. Four months out, the rods were removed in the clinic and she’s got a reasonably well aligned ankle joint and she’s doing as well as you can expect. But here it is. I’ve used it for other cases. This was a very heavy gentleman. He was an ironworker and broke his ankle. I fixated him. Beautiful job. He did this. He didn’t even fall. He did it in a cast. When I had to use that Steinmann rod as a joystick to reduce him and I thought, what the heck. We just ran out right up into the tibia to maintain, give us another point of stability and fixation along with our external fixator. You see he’s a big boy. It leaves those rods sticking up the bottom of the heel and you hope those scare them enough that they won’t stand on it but they do. They don’t care. Here’s another one. This was sent to me by an orthopedic colleague of mine. He did her ankle. She has a posterior dislocation of the foot. The lady was like a bipolar, somewhat difficult. Look at this and put a frame on, yeah, I would to if she’d let me. I had to work within the limitations of her mental status and here I’ve used two Steinmann rods to reduce and stabilize her ankle and I repair her medial malleolus. Medial malleolus by the way is the key to the stability of these ankles. Anne Koval [phonetic] did a number of articles demonstrating that point. Not bad articles for you to read. Anyway, just so you don’t think all I do is transarticular fixation, let’s talk a little bit about some of these senior citizens with the osteoporosis. Very spry gentleman, pleasant and happy, won’t sit down for a second but he broke his ankle while he was fixing his brakes. You see, he’s got an SER. If you look at that x-ray, I don’t know from where you’re at, if you can see the osteoporosis that he has in the comminuted fibula. This is how I fixated this.

[10:00]

Now, there’s a lot to this. This was planned out. I mean you might look at that and say, “Holy cow, they had a party and everyone shot something in there.” We didn’t. We fix his fibula first and then we use the technique described by Koval. This is construction of a fibular cage and we simply shot two K-wires through there and this reduces the bending of the fracture by 81%. The fibular cage is a very effective type of fixation. You see we’ve used hook plate on the medial malleolus. The bone is very soft. I’m working on a little technique here. Now if you take a look, I call this my syndesmotic cage. One screw, four cortices from lateral to medial course just traditional and then another screw from medial to lateral and biting three cortices in this case. I think this is a very stable type of fixation for the syndesmosis. If not, I still have fun doing it. Here’s what he looks like as he’s filling. By the way, this fibular cage, we also use in other parts of the foot and ankle as well. Here, we’ve used it for comminuted, severely displaced fifth metatarsal diaphyseal fracture on a woman about 75 years of age. These wires are sticking out of the foot but you could easily bury them if you come from posterior extending the wires distally. It just adds to the strength of resist axial loading, strong construction. Here’s another one, SER IV, just pronounced osteoporosis. Here, we’ve used bicortical fixation and I’ll show you where that is. It’s right here for the medial malleolus. This is a study, actually, we have done with Pollard from Kaiser Permanente. We did the field testing on this at Wayne State Medical School in Detroit. This type of fixation, bicortical fixation for the medial malleolus was three times stronger than the short cancellous screws for the medial malleolus. This is a very strong type of fixation. You see here, we’ve used a fibular cage and we’ve used three syndesmotic screws in this particular lady. Another one, fibular locking plate, you all know about that so I’m not going to go into any detail about that but we combine this with just one wire for our fibular cage. We have a lag screw and interfragmentary screws through the fibula prior to putting on the locking plate. We have a hook plate medially. We were attempting here to do bicortical fixation. I don’t know if we actually prefer to that cortex or not. I can’t remember but at least you see what we were trying to do with that. Syndesmotic injuries, very quickly case on the right as mine, Weber-C/PER mechanism of injury and we fixated it. Look, I used one screw, there cortices and this is what happened and pulls apart and we have increased gapping of the medial clear space. The image on the left is the guy who had his ankle fixed in Mexico and you see just same thing, even though they used two screws, three cortices, it just didn’t matter, just pulls apart. This is not the strongest type of fixation. Ten and 15 years ago, 20 years ago, it was fine. The whole orthopedic community was using one screw, three cortices but now we know better and we have to stabilize this more. If you look at this trimalleolar fracture, very severe osteoporosis, pronounced diabetic neuropathy, it’s unstable ankle fracture. Here’s how we fixate this. We have a locking plate. We actually have so many syndesmotic screws that is essentially a fibula pro-tibia construction. The orthopedic literature has a lot of articles about this type of fixation. Really, it’s used for like a tibial nonunion but it holds the fibula and the tibia together, draws it in. In the strict orthopedic articles, I mean, it’s using these concepts as originally described. These screws come from medial to lateral and to the fibula. But here, we’re accomplishing the same thing on this diabetic patient. We want absolute stability and rigidity. This thing just does not pull apart. Also, take a look, you can see it for the posterior component reviews, they posterior plate. We no longer drive a screw from anterior to posterior in the indirect method. We have to see this posterior fracture, whether it come from posteromedial or posterolateral. We have to see it. Many times the posterior Volkmann fractures impacted and you can’t reduce just by dorsiflexing the foot. You’ve got to get a key in there, an elevator. Something in there and pull that out of the tibia and realign it. Since we’re right there anyway, we’re going to put the plate where we can see what we’re doing. It doesn’t matter to me if you’re using an antiglide plate or you’re using neutralization plate or you’re using Butcher’s plate, it does not matter as long as you get the plate back there and you protect that and keep it from displacing.

[15:10]

We have 25 minutes left. This is a complicated case. I think I was couple of times in trouble and probably I didn’t even know it. Thirty-five-year-old male, he’s had a heck of a time. A thousand pound plow fell on his ankle and crushed it. This is what it originally looked like. He went to hospital, an orthopedic guy distracted him a little bit. They put him in a temporary frame and then they put him in a more elaborate construction which is good. If you take a look at the AP image, mortise is beautifully aligned. Then I’m not quite sure what happened. I know he had a soft tissue infection. I don’t know if it was osteo. The frame came off and he may have had another operation but this is what it looked like. When he came to our office, this is what the CT and 3D reconstruction looked like. This is a year and a half to two years after he’s original injury. Well, normally I’m not going to take on a case done by somebody else especially a complicated one like this. But the guy was so level-headed and he actually came in for an amputation consult. He had researched the literature. He knew he could get a prosthesis and he knew he could run. He only wanted to work, do his business and run and jog and did not want drugs, no narcotics. I couldn’t believe it. He’s such a nice guy that we decided well, maybe we can help this guy. I want to show you something. All of these worries me, nonunion, there’s loss of bones. It’s this right here that worries me the most because that tends to form an anterior osteonecrosis and that’s bad news. Very difficult to straighten and difficult to correct. I’m going to show you this case and understand. I’m not showing you case where I’ve done the most remarkable job and you guys would say, “Oh, man, you’re cool.” I’m showing you one that really tacks us. This one made us think a few times. Here’s what he looked like prior to us doing any surgery. He collapsed. He went in to a rigid varus. A lot of pain associated with that. We start the reconstruction. We’re using an anterolateral pilon plate and deltoid avulsion plate. If you look at the AP view where I’m applying the deltoid avulsion plate, you see there’s just not bone there. There was a lot of bone grafting and not autogenous bone. This was allogeneic. I have him all built up. This looks great. But men, I couldn’t believe it. On the table, he’d look good. I did not see that. Postoperatively, he’s better but he’s still has varus deformity. We’re obligated and reluctant to this. We have to let him heal. Eventually, the grafts collapsed. He has a rigid varus rearfoot. I did another operation, a tibial opening osteotomy allogeneic bone graft. The varus is corrected. Here’s what he looks like now. That’s nice. Everything looks good. Three months postop, well, I’d like to see some evidence of callus. Look at that fibula. That’s opening up a little bit. Four months postop, he’s got a draining ulcer medially. The bone is absolutely not healing. He’s using bone graft stimulator, nothing is working and ankle is going back into varus. It’s just not going well. Operated again and it was not infected. The drainage was due to the graft just dissolving, decomposing. Debridement of this bone, cleaned him up. You see I’m putting hemostat in. It goes right into the nonunion site. I take out all that fixation. I took that calcaneal graft and the graft is put in this area. This is still an allogeneic scheme to keep that open. This fixation I think was the key that big screw going from medial to the opposite cortex, I think that was much stronger and stable than what we had in. Here he is now in December of last year. If you take a look, he is starting to consolidate right in through here, not this and I wouldn’t expect that to at this point. Look at his ankle joint. Looks kind of crappy, but it’s there and it functions. Look at his range of motion. That’s not bad. Here he is plowing snow in January. We’ve essentially discharged him, although we’ll see him for some final x-rays. He’s doing very well. You look at the x-ray, you think holy cow, he’s crippled. He is not. He is functioning. Here’s a case that really tacks me and you’re planning the bone grafting, the internal fixation and everything.

[20:04]

A very challenging case. We have 20 minutes. This is a ruptured tibialis anterior tendon and we only see one of this maybe every three or four years. This is a classic MRI and you see that lump there and that’s the end of the tendon. I’m just going to whip through this, this is an old injury. There is no history of trauma. The guy presents with a dropfoot and we have to operate and the tendon does not reduce. We took the plantaris and I want you to see this, this is a technique for harvesting and that is – back up, that is a very thin tendon. If you can, you certainly double it up and if you can even fold it in three. This is probably a good tendon for ankle stabilization if anyone still is doing that with free tendon graft but it’s not the thickness that you would think. It’s thicker when you look at it at its insertion on the back of the ankle into the heel. It’s grafted in placed, it’s repaired, tendons reattached. Here’s another case, 41-year-old female. She was at urgent care for head cold, she stood up, pop, felt something snap. Noticed, not a great deal of pain with this but in her case this just happen and we’re able to get the ends of the tendon and do Krackow type of repair and she should do well. She’s in her cast now. I wanted to show you that and I wanted to show you this. This is out of Easley’s [phonetic] book and I think many of you have it or you’re familiar with it and there are a lot of articles written about this. This is a standard orthopedic way to repair a tibialis anterior tendon using the extensor hallucis longus tendon, just to make you aware of that. I don’t do it myself. I don’t like the technique. I don’t like sacrificing that particular tendon for this but it’s there and it’s an acceptable procedure. Now, 18 minutes. Management of soft tissue injuries while they were divided into three types and Myerson is the one that had categorized this for us. Compressive injuries, foot gets run over by high low mangling injuries like a lawnmower chewing off the toes and everything or degloving injuries usually caused by a sheer force like this. You have to take a look the initial evaluation. The history has to be accurate. Neurovascular status, abrasions, lacerations, punctate of wounds through the skin, you have to look at the swelling, the zone of injury, always be aware of knees injuries, compartment pressures, keep that in the back of your mind. The other thing is I’d like to give him an ankle or pop block even in the ER to reduce the severe pain that they have. I don’t think it’s going to mess anything related to compartment pressures. In fact, I really think if it’s a degloving injury soon there’s going to be a compartment pressure problem and measure it as quickly as you can. These are open fractures, open wounds and you have to be familiar with Gustilo classification. I know everyone in this room is. If you take cultures in the ER, that’s fine, we don’t care. There’re some controversies to how accurate they are. You start them on antibiotics but these are cases that go right through surgery and in surgery we do the deep cultures, tissue debridement, pulse lavage, fracture stabilization even as primarily procedure. You do additional débridements every couple of days depending on the injury. Once any infection is resolved and the tissue has demarcated then you can reconstruct. This is a girl that was getting in the car and the guy took off and she got dragged. You see, there’s road rash, there was gravel and crap all through there. You have to excise that area and even a larger area. By the way this ground off from medial malleoli too. Here’s another one. You have to débride this, you have to wash it, scrub it. This is guy missed the step in his backyard and his medial malleolus or what’s left over at the tibia got ground into the ground. That’s grass that you see and we wash that off, we scrubbed it with a Betadine sponge. It wasn’t enough. There was dirt in the cancellous component of the bone. I have to take it burn and grind them down to get all of that out of there. That’s what you need to do. Look at the extent of the injury and keep in mind that damage extends far beyond what you can see. If you take a look, here’s the wound itself and look at where the gangrenous changes are taking place. Always be aware of that if you have a four centimeter wound, the injury especially in a degloving one can extend three times in that area. Well, this is a 41-year-old male. This guy was hit by a train crossing the railroad tracks. Train is going one way. He’s waiting for the last car.

[24:59]

As soon as the last car passed him, he bolted and he didn't know a train was coming from the opposite way. He didn't know he was hit. He ran home, reading the newspaper. Son said, dad, you're bleeding. Then they took his boot off and they could evaluate this. This is a combination of mingling injury and the degloving injury and that's a bad news. He wouldn't let me amputate his toes and we have to wait a few days and I don't have as many pictures as I would like at this, but look at the multiple fractures. Now, I'm going to show you the temporary stabilization. This looks a little silly, but we have to stabilize it. All the studies indicate that certainly the wounds do better. The soft tissue wounds do better when there's fracture stabilization. Whether you use an ex fixes, mini ex fixes, Steinmann rods, Kirschner wires, it doesn't matter. You have to stabilize him. I'm missing some pictures here. He had a bad post trauma course, ischemic dry gangrene set in, demarcation. I took the toes off and then it became obvious, we have to do a transmet amputation and then this is what it looks like. You see the principles here, you can use any type of drain system that you want. I have not found one to be superior to the others. The skin edges are not coaptated well. We're leaving multiple areas for this to drain and that's part of the problem is you're fighting hematoma with this. We did stabilize his midfoot. He needs something that's stable and reduced in the event he would try to do some type of work in the future. And then you wait. You roll up your sleeves. You do everything you can, but you have to wait and see what tissue is viable. This is the first time I used maggot debridement. That gangrene tissue is hard like leather. My hand would get sore debriding it, we’d make the residents go in and then they get mad and won't want to go in and that we'd make our students go on and débride it. We put the maggots, we get them from University of California. In two or three days, it did a tremendous job of debriding this. I'll tell you a story. He went home sleeping with his wife and during the night, a couple of nights after we put this on, the maggots scrolled out under her. He never told her he had maggots in his foot. And she woke up screaming and I don't think this was years ago, I don't think he is sleeping with her yet. I think he is banished to the coach forever. Then, we grafted young man, here's the thing with this guy. He's the nicest guy in the world. I put two pieces of a graft on and over the weekend, he changed his dressing, he thought it look ganky, washed it off. There went $2,000 of grafting material, down his bathroom drain, eventually healed. This is another one. We just treated him recently. He fell off of a train. He works for the railroad. Got his foot caught under the wheels of this car. A young healthy guy, weightlifter and everything. That's what his shoe looks like from the shear injury. Here, we evaluate him. We see the swelling. We see the punctured type wounds. Now look at the hyperextension on the folding of the skin at the base of the toes. Why is that possible? I got to show you this. If you take a look, this is the fifth toe, here’s the bone of the fifth toe. Here is the fourth toe. That's the bone of the fourth toe. Just it's not where it should be. There is no bone in the third toe because that bone is in the second toe. The bone of the second toe was in the first toe. This is a closed very rare degloving injury. The literature indicates only three or four days of ever been reported. The day he came to the hospital, we took him to surgery that night, measured his pressures. We did fasciotomy. I tried to reduce the toes and I couldn't get them all back where they belong. But when I did and I'd let go, they would pop up and go back to the way they used to be. I used the K-wires just to keep the bones in the correct soft tissue envelope. This is what he looks like. But now, you have this injury and you use all the mechanisms you can to get hematoma out of there. The five days postop those pain is getting worse, fracture blisters. Took him back to surgery, pressures are up again and evacuation of hematoma. It's a good sign because under that top layer of skin, he's got some healthy looking skin, I'm somewhat optimistic here. I don't want to get into this because of time constraints. But this is the [indecipherable] [29:45] scheme and I think you are all familiar with it. The problem he kept having was increased pressures especially in the, not just the interossei but the deep central components, we did get that under control.

[29:58]

And then we just have to wait and see what's going to be viable and you see over a period of time, the toes, we can just lift off the tip of the toe in the office and then he had a surgical debridement. I shortened the bone, resected it so that soft tissue would cover the bone. Here is what he is left with and here’s the x-rays. By the way, I took this x-ray in April and look at that high arch. I said, “Oh man, did he get a Dupuytren's type contracture?” and I x-rayed his other foot and it's pretty symmetrical and you see the typical osteopenia. He is wearing regular foot gear now. He has got his spacer in but he still has pain. Nerve type pain and those are Lidoderm patches. This is true with almost all of these degloving injuries. After the skin is healed, they still have discomfort. They have some type of pain. The outcomes in the literature well documented. This people just don’t do well. Hey, this is a great article. This was just published in a brochure in Foot & Ankle Specialist. Look at that dramatic degloving injury. I mean that is a true glove that has come off. It's a good article for you guys to read, written by podiatrist. Gunshot wounds, I don’t have time, for this as much except that we categorize them to low, medium, high velocity. Normally the injuries we see are low velocity gunshot wounds. The muscle velocity has a couple of variables. Usually, we are seeing 22 caliber gunshot wounds, 25, 32, 38, sometimes a 45 and shotgun injuries. The variable here is the grains put into the bullets. This can result in a quite difference in muscle velocity, just a little bit about that. Case report, 46-year-old male, bipolar disorder, shot himself, of course. I went in to see him in the emergency room. This is what it looked like, by the way. A lot of his first met completely. He said to me, “Dr. Fallat, is that you? And I said, yeah. He said, “Remember me? I shot myself in the same foot three years ago and you fixed it.” A little 22 in his third toe and whatever we did and then as we got the history I'd forgotten, somebody beat him up and ran him over or something and broke his leg in the past. We did the surgery debridement. Debridement irrigation, drains are inserted and second procedure more debridement, more irrigation. Here I used an allogeneic spacer to try and maintain length and this is a piece of allogeneic bone right here. The goal was especially working with precedence, we want to try and save everything and reconstruct them. Yeah and that's good, that’s fun to do. But then you wait and the demarcation occurs and then you take off what's not going to be viable. He is actually doing well here and we lost him, he didn’t come back in and a couple of months later, he showed up on the census, he went to one of our sister hospitals, infection, and everything else and the orthopedic guy just did an amputation on him. I think that was the best thing for him. I'm not surprised about the course. These people occasionally, well, how do I put this? In every citizen, will shoot themselves accidentally but we have a whole group of people that, oh, I don't know how to describe, but you guys know what I'm getting at. I'll show this. This guy had a party, gunfire started. Now, look at what he told the police and us. He ran away from the party. He is running and he felt pain and saw a blood in his shoe. Now, if you're running away from a party you don't have to be a forensic analyst to figure out something is not right here. Anyway, we looked at the size of the wound. The condition of the skin had just burn, gunpowder burn, and all the stuff we have to clean up. This is what the x-ray looks like. That's his gunshot wound. We operated on him. We cleaned it out, cultures, and everything. A few days later, by the way, that's not bone. That's a resident putting her finger through the gunshot wound because it's like a clear cut wound. We drained and then we go back in. We cleaned him out again. I missed this on the first time. This is a component of something called a Polyshok Impact Reactive Projectile. This is the first case that has been reported and the foot of this. This is common in the thorax in the body, but not so much in the foot. This is what it looks like. These things really can produce a big cavitation. In the literature, eight inches deep, five inches wide in the torso is not unheard of. This is what it looks like. If you take a look at that hole in his foot on the right, this is actually in our medical article. This is called the fearless Fosdick injury. This guy was a comic strip character in the ‘60s and ‘70s.

[35:01]

How he get shot up like this and his reference for Haden’s [phonetic] article. Anyway, we repair, we cleaned him up. We get him to heal. Here is his fixation. Everything looks pretty good. Lots of followup. We think the guy's injection penitentiary, but we just don't have access to him. But the least you see this unusual case and you see how, yeah, I think, by now, you're seeing the method of how we manage these cases. Here is another one, 21-year-old male, went out to get the mail. And noticed blood was coming out of his foot. He had no idea what happened. He said, “I just looked down and I've been shot.” I don't know what caliber that is. Brandon, do you recall what we decided then? 40 caliber? Okay. Anyway, mash of three bones. I do these cases with Pamela Morrison. She shoves me aside, she takes the bullet out and has to throw the metal base and then make it clanked. As soon she does that, she leaves and okay, you put it back together. We used the mini rail on him and a couple axial resistant K-wires. There are some of them metatarsals. But those bones are shattered, their soft tissue damaged and this just takes a solid six months of healing and then one of the frame off and we did take the frame off and inserted some additional k-wires for further stability, just to stabilize his foot. Just as we has a plantar grade foot structure and then we removed the K-wires in clinic. But it's still a mash and what happened to him, lost to follow up. We don’t know how he is. By the way, when you're running away from a gunfight, you don't get shot on the top of the foot like all of these guys did. You get shot in back of the heel like this guy. In fact you can even see the bullet hit the pavement first before it went in to his Achilles tendon. Anyway, I finished three minutes ahead of schedule. I hope you found this interesting. Thanks for getting up so early on Sunday morning.